The epidemiological transition provides a temporal framework for thinking about the decline of infectious disease and the rise in cardiovascular and other chronic diseases.1 In Europe, the transition began in the late 19th century with improved sanitation and housing, and controls on food adulteration. Continuing public health measures such as vaccination2 contributed to the steep rise in life expectancy during the 20th century, paralleled by a sharp increase in the prevalence of cardiovascular disease (CVD). In South Asia, the epidemiological transition is taking place against a background of economic globalisation that has greatly increased the size of the urban poor and middle classes, at the same time leaving many millions to continue living on the land at subsistence level. Development is socially and regionally uneven, and so too are the common causes of morbidity and mortality. There is a double burden of disease in the countries of South Asia, characterised by a combination of pandemic infectious disease and high rates of cardiovascular disease. That India’s burden of coronary disease was approaching a similar magnitude to that of the established market economies was demonstrabed as long ago as 1990.3

THE LIVES OF SOUTH ASIANS OVERSEAS

Among South Asians in the UK, the latest figures show a continuing excess of CVD and in particular ischaemic heart disease (IHD) deaths.4 5 Based on population data from the 2001 census, standardised mortality ratios for IHD for men and women born in Bangladesh, India and Pakistan are between 131 and 175, using the whole adult population of England and Wales as the reference (SMR = 100). It is important, from research and policy perspectives, to understand the origins of this excess mortality. The question, simply stated, is whether it is biological or social in origin.

Socioeconomic circumstances …